Value of the real-time myocardial contrast echocardiography for risk stratification and for the detection of significant coronary stenosis in patients with end-stage renal disease.

Sir, Coronary artery disease (CAD) is common in patients with end-stagerenal disease (ESRD), and is associated with poor clinical outcome.However, routine screening for CAD in asymptomatic ESRD patientsis usually not required, except for renal transplant candidates[1]. Myocardial contrast echocardiography (MCE) is a new bedsidetechnique providing information regarding myocardial tissueperfusion. The assumption that MCE might be useful in patientswith ESRD has not been previously investigated. Moreover, thereare no published data concerning prognostic utility of MCE inpatients with ESRD. The aim of the study was to assess the prognostic significanceof MCE in patients with ESRD, and to     

Familiality of cardiovascular mortality in end-stage renal disease patients

A very high rate of cardiovascular (CV) death is well recognized in individuals with end-stage renal disease (ESRD). Besides many other factors, this excess risk may also be related to familiality. We tested this hypothesis by estimating the risk of CV death among both ESRD patients and their relatives. In this case-control study, we used the Utah Population Database (UPDB), which includes genealogy records, state-wide death certificates as well as other data sets. These have been linked to the University of Utah Health Sciences Enterprise Data Warehouse which provides multiple diagnosis data sources. Patients with ESRD either on dialysis or who received a kidney transplant were identified in the clinical databases at the University of Utah Dialysis Program and Kidney Transplant Program or from Utah death certificates. CV deaths were identified by the reporting on the death certificates. The relative risks for CV death, adjusted for several potential confounders in the ESRD patients (n = 516) and in their first-degree (n = 2,418) and second-degree (n = 7,720) relatives were estimated in relation to the general population. Using information from death certificates, ESRD patients were found to have disproportionately increased risk for CV mortality (relative risk or RR = 2.4; 95% CI 2.11-2.72), compared to the general population. First-degree relatives of ESRD patients were also found to have an increased CV mortality risk (RR = 1.10; 95% CI 1.01-1.20). When the specific categories of CVD were analyzed, the first-degree relatives also had higher risks for death from acute myocardial infarction (RR = 1.20; 95% CI 1.03-1.40) or heart failure (RR = 1.32; 95% CI 1.12-1.56). An increased risk for CV mortality was, however, not observed in second-degree relatives of ESRD patients, except for the subcategory of hypertensive heart disease (RR = 1.24, 95% CI 1.01-1.49). In conclusion, this study suggests that, in addition to many putative risk factors, the increased risk of CV death in ESRD patients may have a familial contribution.     

Plasma homocysteine levels and cardiovascular mortality in patients with end-stage renal disease

Hyperhomocysteinemia is considered an independent risk factor for atherosclerosis in patients with normal renal function. Plasma homocysteine (Hcy) is increased in patients with chronic renal failure (CRF) and could be linked to their high cardiovascular (CV) morbidity and mortality. We prospectively studied 77 patients (47 males and 30 females aged 62.85 +/- 1.53 yrs) who had been on maintenance hemodialysis (HD) (4 hr/x3/week) for 65.5 +/- 7.23 months. Patients were followed-up for 44 months. At baseline, blood samples were taken for hemoglobin (Hb), total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, serum calcium, serum phosphates, parathyroid hormone (PTH), Hcy, vitamin B12, serum and erythrocyte folate and methylentetrahydrofolate-reductase (t-MTH-FR) genotype determination. Plasma Hcy levels of patients were divided into four quartiles. The univariate analysis demonstrated a significant relationship between Hcy and diastolic blood pressure (BP) (r=0.45; p=0.003), and both plasma (r=-0.30; p=0.03) and erythrocyte (r=-0.48; p=0.01) folate levels and CV score (r=0.39; p=0.007). Kaplan-Meier analysis showed that the mortality rate due to CV events was statistically significantly higher in the 4th Hcy quartile (68%; 12 patients) vs. the 3rd quartile (12%; two patients), the 2nd quartile (28%; four patients) and the 1st quartile (14%; two patients) (log-rank test p=0.02). Cox's regression analysis for CV survival showed that Hcy was a positive CV mortality predictor (beta=0.02; hazard ratio=1.031; 95% confidence interval (95% CI): 1.013-1.050; p=0.001), while LDL cholesterol and albumin related negatively to CV mortality (LDL cholesterol: beta=-0.02; hazard ratio=0.095; 95% CI: 0.0957-0.0997; p=0.035; albumin: beta=-2.35; hazard ratio=0.097; 95% CI: 0.011-0.847; p=0.026). Our results show that Hcy is a strong independent mortality predictor in HD patients with a 3% increase in mortality for each 1 micromol/L increase in plasma Hcy concentration. This agrees with previous findings confirming the role of Hcy in predicting CV risk factors in uremic patients.     

Comparison of tissue Doppler echocardiography parameters in patients with end-stage renal disease and renal transplant recipients

BACKGROUND: Tissue Doppler echocardiography has been introduced as a useful tool to assess systolic myocardial function. In this study we sought to compare patients with end-stage renal disease (ESRD), with renal transplantations and control subjects with regard to tissue Doppler parameters. METHODS: Thirty recipients with functional grafts of overall mean age 36 +/- 7 years included 24 men. An equal number of patients with ESRD of overall mean age 35 +/- 7 years included 20 men. A third cohort was comprised of 20 age- and gender matched control subjects. Tissue Doppler imaging from the septal and lateral mitral annulus of the left ventricle and free wall of the right ventricle was performed from a 4-chamber view. RESULTS: Mean systolic and diastolic blood pressures were similar among the groups during imaging. Peak systolic velocity (S wave) at the septal annulus was similar in control subjects and recipients. S waves were significantly lower among ESRD patients compared with recipients (10.3 +/- 2.1 vs 12.0 +/- 2.5 cm/s, P = .04, respectively). Isovolumic contraction velocity of the septum and the right ventricular wall were significantly lower in ESRD patients than recipients or controls: 10.2 +/- 2.6 vs 12.5 +/- 2.8 vs 11.4 +/- 1.8 cm/s for septal wall (P = .008) and 13.9 +/- 3.6 vs 17.9 +/- 5.1 vs 16.8 +/- 5.8, for right ventricle (P = .01). CONCLUSION: Systolic indices of tissue Doppler echocardiography in recipients demonstrated similar values as control subjects and increased values compared with ESRD patients. These results suggested improvement in systolic myocardial function following renal transplantation.     

Calcium channel blocker use and mortality among patients with end-stage renal disease

BACKGROUND: Patients on dialysis suffer from alarming rates of cardiovascular disease. While calcium channel blockers (CCBs) are prescribed widely to patients with end-stage renal disease (ESRD) for the treatment of hypertension, the long-term outcomes associated with the use of these medications are not known. We sought to determine the association between CCB use and mortality among a cohort of ESRD patients. METHODS: Data were utilized from the United States Renal Data System Dialysis Morbidity and Mortality Wave II, a randomly selected prospective cohort of 4065 ESRD patients who began dialysis in 1996. Clinical data, including medication information, were collected 60 days after the start of dialysis. Subsequent survival status and cause of death were ascertained. The Cox proportional hazards model was used to estimate the relative risk of death associated with CCB use. RESULTS: Data from 3716 patients (91.4%) were available for analysis. Fifty-one percent of the study patients were prescribed a CCB. The use of a CCB was associated with a 21% lower risk of total mortality (RR 0.79, CI 0.69 to 0.90) and a 26% lower risk of cardiovascular specific mortality (RR 0.74, CI 0.60 to 0.91). For patients with pre-existing cardiovascular disease, CCB use was associated with a 23% (RR 0.77, CI 0.65 to 0.91) and 32% (RR 0.68, CI 0.53 to 0.87) lower risk of total and cardiovascular mortality, respectively. CONCLUSION: After controlling for known risk factors and potential confounders, CCBs were found to be associated with a lower risk of mortality among ESRD patients.     

Vitamins are associated with survival in patients with end-stage renal disease: a 4-year prospective study

BACKGROUND: Patients with end-stage renal disease are at high risk from premature death due mainly to cardiovascular disease and infections. Established risk factors do not sufficiently explain this increased mortality. We, therefore, investigated total mortality prospectively in a single-centre study in patients on hemodialysis and assessed the prognostic value of baseline disease status, laboratory variables including emerging risk factors, and the influence of vitamin treatment. METHODS: Patients (n = 102) were followed-up for 4 years or until death (n = 49). Survival was calculated by the Kaplan-Meier method. Cox-proportional hazards model was used to determine independent predictors of total mortality. RESULTS: The known risk factors age, baseline clinical atherosclerotic disease, low albumin and increased cardiac troponin T were significantly associated with mortality. Patients who received multivitamins during follow-up had a significantly lower mortality risk than those not receiving this treatment (hazard ratio 0.29, 95% confidence interval 0.15-0.56). These associations remained significant after adjustment for age, cardiovascular disease, albumin and cardiac troponin T at baseline. CONCLUSIONS: The present study suggests that multivitamin supplementation in patients with end-stage renal disease is closely associated with reduced mortality due to all causes. These observations have to be validated in randomized clinical intervention trials.     

Survival in patients with end-stage renal disease

Based on age and medical condition at the time of treatment, 138 patients beginning dialysis for treatment of chronic renal failure between January 1, 1984 and December 31, 1988, were classified into low, average, and high risk of death. The survival in these three groups was shown to be significantly different after as little as 6 months. The classification scheme is simple, and can be performed at the bedside. Efforts to monitor quality assurance in the dialysis unit must account for the significant differences in expected survival that reflect the case-mix observed in a particular unit.     

Surgical revascularization after acute myocardial infarction in patients with end-stage renal disease.

OBJECTIVE: Cardiovascular disease accounts for over 50% of deaths in patients with end-stage renal disease (ESRD). After acute myocardial infarction (AMI), hospital mortality exceeds 25%, and survival beyond 2 years is <20% for patients with ERSD. The role of coronary artery bypass grating (CABG) in the setting of an AMI in patients with ESRD remains undefined. METHODS: Three hundred and forty-two patients had preoperative ESRD (serum creatinine >2.0mg/dl or dialysis dependence) between 1995 and 2000. One hundred and nineteen patients had an AMI (<7 days) and 223 patients had a remote myocardial infarction (RMI) (>7 days) at the time of CABG. The study group, AMI, was compared to the RMI group, which served as a comparison group. RESULTS: The age (69 vs. 67 years), males (68 vs. 67%), creatinine (3.18 vs. 3.76 mg/dl, P=0.06), and preoperative dialysis (19 vs. 22%, P=0.52) were similar in either the AMI or RMI group, respectively. The frequency of diabetes, hypertension, dyslipidemia, previous myocardial infarction were common, yet not different between groups (P=NS). For either AMI or RMI group, multivessel CABG (96 vs. 94%, P=0.73), off-pump CABG (OPCAB) (22 vs. 18%, P=0.67), and arterial conduits (71 vs. 78%, P=0.42) were similar. Among postoperative events, only pulmonary complications (33.8 vs. 14.7%, P=0.049) and atrial fibrillation (48 vs. 29%, P<0.001) were more common in the AMI group. Hospital mortality was no different between the AMI and RMI groups (10 vs. 8.5%, P=0.88). CONCLUSIONS: Although patients with ESRD that have an AMI or RMI represent high risk groups, perioperative outcomes suggest that patients selected for CABG as an early treatment strategy in the setting of an AMI represents a viable therapeutic option.     

Unique risks for mortality in patients with end-stage renal disease undergoing nonemergent colorectal surgery

Background

The aim of this study was to identify unique risk factors for mortality in patients with end-stage renal disease undergoing nonemergent colorectal surgery.

Methods

A multivariate logistic regression model predicting 30-day mortality was constructed for patients with end-stage renal disease undergoing nonemergent colorectal procedures. Data were obtained from the National Surgical Quality Improvement Program (2005–2010).

Results

Among the 394 patients analyzed, those with serum creatinine levels >7.5 mg/dL had .07 times the adjusted mortality risk of those with levels <3.5 mg/dL. For colorectal surgery patients, the average serum creatinine level was 5.52 ± 2.6 mg/dL, and mortality was 13% (n = 50).

Conclusions

High serum creatinine was associated with a lower risk for mortality in patients with end-stage renal disease, even though creatinine is often considered a risk factor for surgery. These results show how variables from a patient-centered subpopulation can differ in meaning from the general population.     

递增式血液透析对终末期肾病患者肾功能、微炎症及死亡率的影响

目的研究递增式血液透析(IHD)对终末期肾病(ESRD)患者肾功能、微炎症及死亡率的影响。 方法选取2017年7月至2021年6月于我院行血液透析(HD)治疗的ESRD患者84例,按照随机数字表法将84例ESRD患者分为递增组(n＝42)与常规组(n＝42)。治疗前及治疗6个月后,观察两组透析充分及生存情况、血尿素氮(BUN)、胱抑素C(CysC)、血清肌酐(Scr)、残余尿量(RUV)、尿素氮下降率(URR)、Kt/V等肾功能指标,血清C反应蛋白(CRP)、白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)和β2微球蛋白(β2-MG)等微炎症指标,以及透析期间不良反应。 结果与常规组相比,递增组透析充分率增高,死亡率降低(P<0.05)。治疗6个月后,与常规组相比,递增组的BUN、CysC、Scr、RUV降低;URR、Kt/V增高(P<0.05);血清CRP、IL-6、TNF-α及β2-MG水平降低(P<0.05);不良反应发生率降低(P<0.05)。 结论IHD可以保护ESRD患者的残余肾功能,抑制机体微炎症,降低不良反应率和死亡率。     

N-terminal pro brain natriuretic peptide predicts mortality in patients with end-stage renal disease in hemodialysis

Concentrations of N-terminal pro brain natriuretic peptide (NT-proBNP) increase in patients with heart failure and other cardiovascular (CV) diseases and are strong prognostic markers. In patients with end-stage renal disease (ESRD) in hemodialysis (HD), levels of NT-proBNP are almost always raised. In ESRD patients undergoing HD, we aimed at (i) identifying the factors that affect levels of NT-proBNP, (ii) determining the effect of HD on NT-proBNP, and (iii) determining the prognostic impact of NT-proBNP. A total of 109 patients underwent physical examination, electrocardiogram, and echocardiography. Serum NT-proBNP was measured before and after HD (Elecsys 2010). NT-proBNP levels were markedly elevated (pre-HD 4079 pg/ml, post-HD 2759 pg/ml, P<0.001). There was a strong inverse correlation between NT-proBNP and left ventricular ejection fraction (LVEF) (P=0.043), 24-h urine production (P=0.006), and K(t)/V (efficacy of dialysis) (P=0.016) and a positive correlation with left ventricular hypertrophy (LVH) (P=0.014). Patients with higher concentrations, both pre- and post-HD had an increased mortality rate compared to those with lower concentrations (P=0.007, P=0.002). We found age (P=0.009) and NT-proBNP (pre-HD P=0.007, post-HD P=0.001) predictive of death. Our findings demonstrate that CV disease in terms of LVH and reduced LVEF in addition to 24-h urine production and K(t)/V determine NT-proBNP levels. Post-HD levels of NT-proBNP were lower than pre-HD levels; both predictive of mortality.